Healthcare Provider Details

I. General information

NPI: 1427506658
Provider Name (Legal Business Name): JESSICA KUILAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 GATE PARKWAY BLDG 100, SUITE 100
JACKSONVILLE FL
32256
US

IV. Provider business mailing address

5011 GATE PARKWAY BLDG 100 SUITE 100
JACKSONVILLE FL
32256-0830
US

V. Phone/Fax

Practice location:
  • Phone: 305-783-3991
  • Fax: 305-230-7616
Mailing address:
  • Phone: 305-439-6969
  • Fax: 305-230-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13911
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: